What is the impact of long-term COVID-19 on workers in healthcare settings? A rapid systematic review of current evidence

Background Long COVID is a devastating, long-term, debilitating illness which disproportionately affects healthcare workers, due to the nature of their work. There is currently limited evidence specific to healthcare workers about the experience of living with Long COVID, or its prevalence, pattern of recovery or impact on healthcare. Objective Our objective was to assess the effects of Long COVID among healthcare workers and its impact on health status, working lives, personal circumstances, and use of health service resources. Methods We conducted a systematic rapid review according to current methodological standards and reported it in adherence to the PRISMA 2020 and ENTREQ statements. Results We searched relevant electronic databases and identified 3770 articles of which two studies providing qualitative evidence and 28 survey studies providing quantitative evidence were eligible. Thematic analysis of the two qualitative studies identified five themes: uncertainty about symptoms, difficulty accessing services, importance of being listened to and supported, patient versus professional identity and suggestions to improve communication and services for people with Long COVID. Common long-term symptoms in the survey studies included fatigue, headache, loss of taste and/or smell, breathlessness, dyspnoea, difficulty concentrating, depression and anxiety. Conclusion Healthcare workers struggled with their dual identity (patient/doctor) and felt dismissed or not taken seriously by their doctors. Our findings are in line with those in the literature showing that there are barriers to healthcare professionals accessing healthcare and highlighting the challenges of receiving care due to their professional role. A more representative approach in Long COVID research is needed to reflect the diverse nature of healthcare staff and their occupations. This rapid review was conducted using robust methods with the codicil that the pace of research into Long COVID may mean relevant evidence was not identified.


Introduction
Long COVID (LC) has rapidly emerged as a long-term debilitating illness [1] described by the World Health Organisation (WHO) as "devastating" [2].Health and social care workers have a higher prevalence of self-reported LC compared to other occupational groups [3].For health care workers (HCW), this is likely to be due to an increased risk of exposure and their central role in caring for patients with COVID-19, especially early in the pandemic when little was known about the virus, and many months before a vaccine was introduced [4].
The current joint NICE, SIGN and RCGP guideline on the management of long-term effects of COVID-19 (NG188) provides the following definitions: • Acute COVID-19: Up to 4 weeks • Ongoing symptomatic COVID-19: From 4 weeks up to 12 weeks • Post-COVID-19 syndrome: Continuing for more than 12 weeks and not explained by an alternative diagnosis [5] The term 'Long COVID' encompasses ongoing symptomatic COVID-19 and post-COVID-19 syndrome definitions above (i.e., signs and symptoms from 4 weeks after acute COVID- 19).
Long COVID is an emerging condition for which a clear treatment care pathway or management options have yet to be established.However, given NHS workers have been disproportionately affected by LC, NHS England has put support measures in place, including occupational health, mental health hubs and guidance for health professionals returning to work, and for managers of these staff [6].The Scottish Government has pledged £10 million over three years for LC support, although not specifically directed to NHS workers.
At present, there is limited evidence about narratives and experiences of those living with LC and their abilities to self-manage its consequences.In addition, there is little information specific to healthcare workers on the prevalence of LC, its pattern of recovery and its impact on healthcare resources.
This rapid systematic review focuses on the experiences of those working in healthcare settings and with LC symptoms, the impact on self-reported health, professional working lives, personal circumstances, and use of health services.

Methods
A systematic rapid review was conducted and reported in adherence to the PRISMA 2020 statement and the Enhancing Transparency in Reporting the Synthesis of Qualitative Research Statement [7,8].The methods for this appraisal were pre-specified in a research protocol (PROSPERO database registration number: CRD42021288181; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=288181)

Eligibility criteria
Eligible studies were written in English, published from December 2019 in a peer-reviewed journal and assessed participants with LC.Initial searches were conducted in November 2021 and were updated in December 2022.Evidence was considered from studies of any design reporting the experiences and/or impact of LC symptoms in HCW and including working performance, personal circumstances, or use of healthcare resources in healthcare workers.Eligible studies reported a definition of LC, or the criteria used to identify participants with LC symptoms.Clinical and non-clinical staff were eligible for inclusion.Social care staff and staff working in care homes and other long-term care facilities were not eligible for inclusion.Opinions and commentaries were excluded.
Studies reporting quantitative data only were grouped for narrative synthesis.Studies reporting qualitative data were grouped under emerging narratives and themes.

Information sources and search strategy
A highly sensitive search strategy was developed by an information specialist (PM).The search strategy included database index and free-text terms to encompass the two facets of the longerterm effects of COVID-19 and all categories of workers in healthcare settings.A range of clinical and social science databases was searched, including Medline, Embase, CINAHL, Web of Science, PsycInfo, and ASSIA.There was no restriction on language or study type at the search stage.Results were limited to those published from December 2019.Searches were all carried out in November 2021 and updated in December 2022.The reference lists of all studies selected for full-text appraisal were screened for additional studies.A sample Medline search strategy is presented in S1 Appendix.

Study selection
One reviewer (MC) screened all titles and abstracts identified by the initial and updated literature searches and a second reviewer (MB) screened those selected for full-text screening.One reviewer (MC) screened all potentially eligible full-text reports and those considered eligible were checked by a second reviewer (MB).Studies selected for inclusion were cross-checked by two experts (AG, NT).

Data collection, quality appraisal and data synthesis
One reviewer (MC) conducted data extraction and a second reviewer (MB) checked the data extracted by the first reviewer.A third reviewer (AG) independently extracted data and crosschecked with the data agreed by the first two reviewers.For the updated searches, four reviewers (MC, AG, NT, MB) conducted data extraction and all extracted data were cross-checked by one reviewer (MC).At all stages, disagreements were resolved by consensus.
The following information was recorded from each included study: research question and setting, objectives and methods, demographic characteristics of participants, definition of LC, symptoms of LC, self-reported information on health status, effects of LC on working life or personal circumstances, use of healthcare services resources, and interpretation of findings from studies' authors.
The methodological quality of the included studies was assessed by a single researcher (MC) using the Quality of Reporting Tool (QuaRT) [9] and double checked by a second researcher (MB).
A pragmatic approach was adopted for the analysis of the results of the identified studies.Three researchers (MC, MB, AG) examined the qualitative studies to identify the main prominent and recurrent themes, organised the findings under 'descriptive' thematic headings and produced a holistic interpretation.

Study selection
The initial literature searches identified 2089 records which were screened for relevance.Of these, 56 were considered potentially relevant and selected for full-text assessment.A total of 14 papers reporting 12 primary studies met the inclusion criteria.The updated searches identified 1681 records.A further 18 studies met the inclusion criteria and were included in the review, giving a total of 30 studies published in 32 papers.
A PRISMA flow diagram detailing the study selection process is presented in Fig 1.

Studies' characteristics
Of the 30 included studies, two provided qualitative evidence [10,11] and the remaining 28 survey studies used quantitative methods for collecting data on persistent COVID-19 symptoms .The two qualitative studies were both conducted in the UK and recruited 43 participants [10] and 13 participants [11], respectively, with more than half of participants being medical doctors or GPs.Median age was 40 years in one study [10] and the age of most of participants in the other study was between 30 and 39 years [11].The research question was described in most studies, but the study design was justified in only a few studies.Participant selection and recruitment were reported adequately in most studies, as were data collection and analysis methods.Only one study failed to report all domains adequately [13] while four studies reported all domains adequately [10,11,14,15].In general, the quality of the identified studies was judged to be satisfactory.

Results of qualitative studies
From the two included qualitative studies [10,11], we identified five themes related to the experience of health workers with LC: 1. Uncertainty about symptoms Each of these themes is summarised below.Uncertainty about symptoms.Participants experienced and described unfamiliar, unpredictable, and fluctuating symptoms which did not fit their clinical knowledge.
As healthcare workers, participants were able to recognise their physical and mental symptoms but struggled to make sense of the nature and duration of these symptoms and they expressed concern about returning to work too soon or before the complete resolution of symptoms.
Most participants described a deterioration in their ability to carry out everyday tasks, including clinicians concerned about the safety of their practice, and raised concerns over whether they would ever recover or return to work.
It's difficult because I keep getting new things, which is one of the frustrations of this.The brain stuff seems to be getting better, to the level that I can function.When the brain wasn't working that made me very scared because I need my brain!Not to be blase ´, but with the chest pain and stuff I can still work because I can work remotely.If I don't have my brain I can't work, I can't plan, I can't string a sentence together. . .I did get a bit scared when I was ill for so long. ..(Doctor;Taylor 2021) [11] Those who had returned to work worried that they were not able to cope at the required level or contribute enough to the workplace.Participants turned to online social media groups for support and information.They also expressed newfound empathy for patients suffering from post-viral states and/or for those whose test results had not find anything conclusive.
It wasn't an active prejudice, but in the back of my mind I hadn't thought about it. . .a number of us in the group have said how ashamed we are of some of the attitudes we've had towards people, and lack of empathy. . .This concept of being irritated by patients when they're not really pleased when something comes back normal. . .Hopefully, it will make me a better and more empathetic doctor at the end.(Doctor; Taylor 2021) [11] Difficulty accessing services.Participants described problems accessing and navigating care.They experienced delayed, absent, or inappropriate responses and perceived a lack of interest and support from their GPs in acknowledging and investigating their symptoms.In the study by Taylor et al., the doctors reported that their professional expertise had not been recognised or taken seriously, and some participants had called on personal contacts to secure appointments or referrals to specialists."I'd messaged a friend from medical school who's a cardiologist as I was wondering about pericarditis. . .I've always tried to be a good patient and go through my GP and things, but it wasn't working.So that's when I started messaging people and calling in favours."(Doctor; Taylor 2021) [11] Participants reported also accessing private consultations for investigations, where positive test results helped them access specialist NHS referral.
"My friend said "if you've got a mate in cardiology then ask for an echo".So I did.And I don't normally like to ask for favours. . .I reached out and he said "if you pay the fees for the echo then we'll do it". . .I felt disappointed I was unable to access this on the NHS.[. ..]" (Doctor; Taylor 2021) [11] Participants reflected on the lack of clinical pathways for LC and advocated a coordinated and multi-disciplinary approach.
The importance of being listened to and supported.Participants emphasised the value of being listened to by a clinician.

"Then I spoke to my normal GP when she got back and that was probably the single most helpful conversation that I had during all of this because she, I was really struggling with how bad the fatigue was. . . I couldn't really have a shower without an hour's sleep afterwards and was feeling absolutely awful. Just feeling really grotty all the time. And she completely validated that I wasn't one of her nightmare patients." (Doctor; Taylor 2021) [11]
Continuity of carer was important for participants as their story was often lengthy, unfamiliar, and multifaceted.
The focus when you do get a new GP speaking to you seems to be that they go back to the beginning and I've had a few consultations where I know I don't need to go to the hospital but your assessment is really all-around 'do I stay at home and wait this out or do I go to the hospital?' and there's nothing in between that.And I think if there was the same GP who we are able to consult regularly they would build a picture of your baseline and I think that's what's lost with digital ways of working.(Doctor; Ladds 2020) [10] Similarly, online LC support groups were considered important for reassurance, validation, and the opportunity to engage with others.
Patient versus professional identity.Combining their professional identity as healthcare workers with their role as patients was found particularly challenging by the participants.
I have found it very difficult to dissociate my doctor's brain from my patient's brain.I found it very difficult to. . .I'm a trainer as well, and I found it very difficult to dissociate my educator's brain from my patient's brain so I've had that dynamic going on for several weeks.I said to him "I hope I've handed over that locus of control, I'm putting trust in you, you're looking after me, I will go by your advice" (Doctor; Taylor 2021) [11] Because of their own professional experience, participants were fully aware of the doctorpatient relationship and recognised that the uncertainty of their symptoms was somewhat difficult to address from a doctor's perspective.They feared they could have been perceived as a burden.
They were also frustrated by the fact that their doctors did not perceive and treat them as 'patients' and struggled to understand the expectation that, as healthcare workers, they were left to decide their own treatment.
[My GP] does rely heavily on me being a doctor and making my own management plan. . .There's a place for ICE [Ideas, Concerns and Expectations] but I need someone to be my doctor.If I don't come up with something, it's "wait and see", or a blood test (Doctor; Taylor 2021) [11] Based on their experience of patients experiencing uncertain and persistent COVID symptoms, participants also reflected on their role as healthcare workers and their attitude in dealing with patients' concerns and requests in the past.Their own experience was an opportunity to re-evaluate the needs of patients and adopt a more sympathetic approach in the future.

Suggestions to improve communication and services for people with Long COVID.
Based on their own experience of LC, participants felt an obligation to share their insight and raise awareness.
I mean not to sort of self-grandiose our group but there's a certain responsibility to put down our experiences so they can be opened up to other people who don't have the language and the access that we potentially have to communicate it to primary healthcare to access the services that need to be put in place for them (Doctor; Ladds 2021) [10] Participants reflected on how to overcome the limitations of the current health services for patients with COVID.They advocated a multi-disciplinary approach to identify and address LC symptoms and the need for more personalised services.
My expectation of such a clinic would be to rule out treatable causes or complications, based on our symptoms.And then active involvement with physiotherapies and occupational therapies maybe a psychologist [. ..] we now know that COVID is a multi-system disease so the fact that you don't display signs of respiratory infection doesn't mean that you don't have a problem.(Allied healthcare professional; Ladds 2021) [10] Some participants also suggested establishing user-friendly online or telephone services to provide reliable information to people with LC.

Results of quantitative studies
Twenty-eight of the included studies assessed the symptoms of healthcare workers experiencing LC.A summary of the characteristics of these studies is presented in Table 1, along with a summary of the studies' findings.
Six studies assessed the impact of LC symptoms on the working life of HCW.One study reported a median 10 missed working days in those with symptoms lasting <90 days and median 21 missed working days in people with symptoms lasting <365 days.[15] Four studies reported that workers' long-term symptoms disrupted their working life [14,26,28,29].Some participants reported that their social life and home life were disrupted by the persistence of their symptoms [14] and others reported being unable to participate in leisure activities because of their ongoing symptoms [18].Conversely, one study reported that around threequarters of HCW were leading a healthier lifestyle in the form of physical activity or taking multivitamins during the post COVID-19 recovery period [19].

Risk of bias assessment
The findings of the Quality of Reporting Tool assessments for the 30 included studies are reported in Table 3.

Discussion
Our systematic review identified 28 survey studies assessing the presence and impact of LC symptoms among HCW and two qualitative studies assessing their experiences and narratives.In general, quality assessment of the studies found them to be adequately reported.
HCW reported a wide range of diverse symptoms they have attributed to LC.The number and diversity of these LC symptoms have led to considerable challenges in achieving any formal diagnoses, investigations, management plans and prognosis, for those affected.This is reflected in the findings of this review.
The participants clearly described the difficulty of combining their dual role as healthcare workers and patients and some recognised the challenge their doctors faced in managing a novel condition but felt that the onus was on themselves to provide answers to their questions.
Evidence already exists in the literature on how healthcare workers are susceptible to physical and mental illness [40,41].It is, therefore, no surprise that the studies included in this systematic review reported that long-term symptoms following COVID-19 infection were common among healthcare workers.In the survey studies, physical symptoms were reported more frequently than psychological symptoms but having professional medical knowledge did not protect the healthcare workers from the uncertainty and consequent fear about the nature and course of their symptoms.Furthermore, working in the healthcare sector was not an advantage in finding appropriate care.The impact of the problems experienced by people who experienced LC and the need to be listened to and supported by their doctors has been documented in the literature [42].A systematic review assessing the barriers health professionals experience in accessing healthcare has highlighted important similarities between them and the general population [43].
Healthcare workers and especially doctors tend to consider their professional identity their core identity, which is often associated with a strong sense of power and the belief to be 'invincible' [44].It is, therefore, challenging for their medical self to recognise their own illness and vulnerability.The pre-COVID literature already shows that doctors who have been away from work because of illness tend to internalise the perceived negative response of colleagues and their families to their problems, consider themselves as failures, and express self-stigmatisation  are invincible' may allow doctors to maintain their strong medical identity but be more accepting of their own limits [44].

Strengths and limitations of the review
Extensive searches were conducted to identify relevant literature and two reviewers were involved in the selection of relevant studies and data extraction.Despite comprehensive searches, it is possible that relevant literature was not identified and it is likely that further relevant literature has since been published, given the fast-paced nature of research into the COVID-19 epidemic and its long-term sequelae.However, in the context of a rapid review, the methods used were robust and by current methodological standards.A potential limitation of our review is that we were not able to investigate associations between the effects of vaccination and LC symptoms, or the difference in LC symptoms between males and females, as they were not reported consistently by included studies.We recommend that future studies consider these potentially informative aspects.There was limited research on UK NHS workers, and the participants of these studies were largely doctors, white and from Western populations.A more representative approach is needed to reflect the diverse occupations and ethnically varied nature of HCW.

Conclusion
Having a medical background did not help healthcare professionals make sense of the wide range of debilitating and unpredictable LC symptoms.The dual role of being a patient and a doctor was particularly problematic and they felt dismissed and unheard by their doctors/clinicians.They reported a variety of persisting symptoms but low levels of sick leave and the need for multidisciplinary care was highlighted.There was little research on NHS workers and participants were mainly doctors, white and from Western populations.

2. Difficulty accessing services 3 .
Importance of being listened to and supported 4. Patient versus professional identity 5. Suggestions to improve communication and services for people with LC.

a
Seropositive participants only; b 181 participants at days 31-60 and 148 participants at days 61-90 (positive PCR test); 581 participants at days 31-60 and 515 participants at days 61-90 (negative PCR test).Percentages shown are for participants with a positive PCR test and as proportions of daily recordings of the symptom c Original publication does not report exact numbers of participants experiencing each symptom.Therefore, percentages are approximate.d PCR evidence of infection https://doi.org/10.1371/journal.pone.0299743.t001

Table 3 . Risk of bias of included studies, as assessed by the quality of reporting tool.
https://doi.org/10.1371/journal.pone.0299743.t003